Project Summary/Abstract The overall goal of this project is to establish a Patient Safety Learning Laboratory to advance patient safety for critically ill newborns during medical ground or air transport from one hospital to another within a regional network. The project will use a five-stage innovation cycle, including: problem analysis, design, development, implementation, and evaluation to identify and address the salient issues and risks of regional neonatal transportation for which new and innovative approaches are needed. In collaboration with transport providers and other stakeholders, we will analyze current workflow processes, transport records (local and statewide databases), and facilities at referral and receiving facilities to develop a complete understanding of system issues and to define the current and ideal states. This detailed problem analysis phase will enable the redesign of clinical workflow processes to optimize regional consultation, triage, and transport of newborns to facilities with the appropriate level of care and availability of space and staffing. With the input of clinical transport team staff and stakeholders, the project team will work with collaborators from the University of Washington Industrial and Systems Engineering Department to design and develop a novel, secure, Transport Monitoring and Communications (T-MAC) system to enhance video communication while on transport. The T-MAC system will undergo repeated testing and revision to ensure that it can functionally and efficiently facilitate information flow between the medical control physician, referring facility and transport team. In addition, we will develop robust documentation processes that can conveniently be used during the transport that includes checklists that prompt safety behaviors and provides a robust dataset for tracking adverse patient safety events. To accomplish this, we will work with transport team providers to create forms that are suitable for electronic documentation with the goal of streamlining documentation on transport and facilitating identification of transport-specific safety issues. The efficacy of the T-MAC system will be evaluated in a realistic in situ and data-driven 3D visualization models. We are confident that the lessons learned through this study will improve neonatal patient safety on medical transports and will be transferable to patient populations that undergo medical ground or air transports over large geographical regions.